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Methotrexate

Key points Methotrexate (MTX) remains a safe and effective modality for the treatment of severe, recalcitrant psoriasis when used appropriately. The exact mechanism of action of MTX in psoriasis is unknown, but it is thought to involve an immune modulatory effect on the T-cell–mediated inflammation in psoriasis. Studies demonstrate improvement of psoriatic lesions using 10 to 25 mg per week MTX as a single oral, intramuscular, or…

Psoralen-Ultraviolet Light A Therapy

Key points Psoralen-UV-A (PUVA) photochemotherapy involves use of either an oral or topical psoralen followed by exposure to long-wave UV-A radiation. This combination leads to a clinically beneficial phototoxic response, which has been used therapeutically for a wide array of dermatoses. PUVA is an effective form of therapy for chronic plaque-type psoriasis with the potential for induction of long-term remission. Use of PUVA photochemotherapy has become…

Ultraviolet B Phototherapy

Key points Phototherapy with UV light can be used in the treatment of several cutaneous disorders. Phototherapy is an efficacious treatment option in the management of psoriasis and should be a first therapy considered in patients with moderate-to-severe plaque psoriasis. Narrowband UV-B is used as the first-line phototherapy treatment option for moderate-to-severe psoriasis due to its clinical efficacy and mild side-effect profile. Targeted UV-B therapy phototherapy…

Overview of Psoriasis

Key points Today, psoriasis is a global disease causing significant impairment in quality of life, disfiguring morbidity, and increased mortality. Psoriasis affects men and women equally. Two-thirds of patients are thought to have mild disease, and one-third of patients are thought to have more severe involvement. Psoriasis is found in practically all racial groups and is thought to affect approximately 2% of the world’s population. Psoriasis…

Dermatology Office Accreditation

Chapter Summary Accreditation focuses on the quality of patient care provided while Medicare standards tend to focus on the physical aspects of the healthcare facility and environment. Accreditation surveys review every aspect of a healthcare facility and confirm that the facility does what it says it is doing. A year-long preparation for an accreditation survey is usually necessary. A consultant can provide helpful guidance regarding state…

Design of the Surgical Suite, Including Large Equipment, and Monitoring Devices

Chapter Summary Design and plan the suite about 12–18 months in advance of the anticipated starting date for using the suite. Consult experts in medical office design and construction. Decide which type of surgical facility is right for your practice. Decide if accreditation should be pursued. A bigger facility can often be better in the long term. Ensure patient privacy. Plan for plenty of storage. Ensure…

Assessment and Treatment of Photoaging-related Mottled Pigmentation

Chapter Summary Photoaging-related mottled pigmentation is a common manifestation associated with other dermatoses, including solar lentigines and melasma. Combination treatments must be individualized to each patient based on the pattern and cause of the pigmentation. Treatment targets are broadly divided into epidermal pigmentation and dermal pigmentation. Vascular changes in the dermis can be important additional treatment targets. Q-switched lasers with a pulse duration of nanoseconds are…

Hidradenitis Suppurativa

Chapter Summary Hidradenitis suppurative (HS) is a chronic, recurrent inflammatory disease of the skin. Patients with HS may suffer with systemic associations and/or complications in addition to skin lesions. HS greatly affects quality of life and may have huge physical and emotional impacts on those with this disorder. There are a variety of procedural options in the therapeutic armamentarium for HS. Introduction Background Hidradenitis suppurativa (HS)…

Repair of the Split Earlobe, Ear Piercing, and Earlobe Reduction

Chapter Summary The ear, and particularly the earlobe, plays a significant role in appearance, and has traditionally been adorned with earrings. The auricle consists of skin and cartilage, whereas the earlobe consists of skin and fibrous fatty tissue and is devoid of cartilage. The earlobe is easily split as a result of the weight of earrings. The ears and the earlobes are prone to the formation…

Nail Surgery

Chapter Summary Nail surgery is delicate and requires in-depth knowledge of the anatomy and biology of the nail as well as surgical skills and special experience in this particular field. Optimal patient preparation, exact planning for what shall be done, efficient local anesthesia, complete asepsis, and consistent postoperative follow-up usually lead to a good result that is gratifying to the patient and surgeon. Although nail surgery…

Leg Ulcer Management

Chapter Summary Most leg ulcers are the result of venous disease, arterial disease, neuropathy, or a combination of the three. A careful medical history and thorough physical examination is critical to the diagnosis and management of leg ulcers. Compression therapy is the mainstay of venous ulcer treatment. Bacterial colonization of chronic wounds may not adversely affect healing and need not be treated as an infection in…

Mohs Micrographic Surgery and Cutaneous Oncology

Chapter Summary Mohs micrographic surgery is a specialized surgical procedure indicated for basal cell carcinoma, squamous cell carcinoma, melanoma, and other malignancies of the skin and mucous membranes. Mohs micrographic surgery provides complete microscopic margin control through the use of horizontal frozen histologic sections of the entire periphery of the excised tumor. Mohs surgery is cost-effective and provides the highest cure rate for tumors that spread…

Vitiligo Surgery

Chapter Summary Surgical treatment of vitiligo is an effective technique for treating stable cases. The absence of progression of disease for a period of 1 year has been recommended as an optimum period for stability. The patient should be adequately counseled regarding the limitations of the procedure and the possible future progression of the disease. The selection of technique depends on the extent, site, and type…

Keloid Management

Chapter Summary Keloids are a hyperproliferative response of connective tissue to trauma, appearing most commonly in areas of high skin tension. Their etiology and pathogenesis are poorly understood, though multiple endocrine factors may play a part, and there is evidence of genetic predisposition. In the early stages, diagnosis may be difficult, but mature keloids are easily distinguishable from hypertrophic scars. Keloids often itch, burn, and cause…

Rejuvenation of the External Female Genitalia

Chapter Summary The normal aging process of the female genitalia is modulated by a variety of influences, including heredity, childbirth, environment, culture, diet, exercise, past illnesses, and others. Hyaluronic acid-based dermal fillers are being used as a treatment for volume restoration in the mons pubis and labia majora. The requests for reduction of the labia minora have increased in the last years. Different surgical approaches for…

Rejuvenation of the Neck Using Liposuction and Other Techniques

Chapter Summary Evaluate submental adipose tissue, skin elasticity, and platysma laxity Neck liposuction is appropriate for those with pre-platysmal fat, good skin quality, and absence of platysma bands. Laser-assisted liposuction can be beneficial in patients with submental fat and lax skin. Add platysmaplasty for patients with good skin quality but with a non-decussated, lax platysma. Patients with poor skin quality may require superficial musculoaponeurotic system plication,…

Blepharoplasty and Brow-lift

Chapter Summary The goals of blepharoplasty and brow-lift are to restore the youthful appearance of the eyelid–eyebrow unit with a perfect functional result and optimal facial aesthetic appeal. Today's aesthetic eyelid surgery rejuvenates by contouring and repositioning the orbital fat, restoring the convexity of the lid–brow junction, and elevating the brow whenever brow ptosis is present. Profound knowledge of the anatomy and all operating procedures necessary…

Vertical Vector Face Lift with Local Anesthesia

Chapter Summary As facial soft tissue ptosis develops with advancing age, the vector of descent is primarily downward with gravity. The vertical vector face lift removes excess adipose tissue of the neck and jawline, reverses the gravity-associated descent of the SMAS, and restores a youthful balance to the aging face. The vertical vector of SMAS plication and fixation of platysma to mastoid fascia results in minimal…

Lamellar High-SMAS Minimum Incision Face Lift

Chapter Summary In most parts of the face and neck, a component of the superficial musculoaponeurotic system (SMAS) lies just deep to the subcutaneous fat. SMAS elevation by suspension with deep anchorage can provide stable correction of mid-face, lower face, and neck ptosis. Optimal suspension of the SMAS layer requires the release of retaining ligaments beneath this fascia (in the deep plane) in order to increase…

Endovenous Thermal Ablation Techniques with Ambulatory Phlebectomy for Varicose Veins

Chapter Summary Endovenous thermal ablation (ETA) procedures are advantageous for the treatment of primary varicose veins over both stripping surgery and foam sclerotherapy. Most evidence exists for endovenous laser ablation (EVLA) and radiofrequency segmental ablation (RFSA). ETA procedures can prevent the complications of varicose vein disease. Preoperative duplex ultrasound (US) investigation of the complete superficial and deep venous system and in particular of the veins to…